FIELD DOCUMENTS_PART 1 FILE 1 - Laserfiche WebLink

Home Browse Search

ICATION FOR WELL/PUMP PERMIT SAN JCMUIN COUNTY PUBLIC HEALTH SERVk _3 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 Y Y C�� / (209) 468-3420 �y tPT NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Trlplieate) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A{PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11 5.3 AND TH STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNNI MI6777 /•how/u.�o/ Rd, /Jrd^/�D QS Clry_LaThrvp PARCEL SIZE/APN# OWNER'S NAME. �/./�. S//Yj�/7/p f ADDRESS 16777 /-1qw 1p„p1 ,ice P ONE# ft 58-2511 CONTRACTOR 61?O9 /ry C , ADDRESS 202 r/q/ UC# PHONE# svo i'sT-REX c s 7tr�r>►ec SVR CONTRACTOR ADDRESS UCI PRONE I 7-t4 TG'wKl vR a n>• pC S/�728 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONUORma WELL# "91' ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# •/ (TYPE OF P1MP1 11 Now 11 REP epelr H.P. DTH PUMP SET FT. FIRST WATER LEVEL _ 0 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING /) R ®DESTRUCTION: L' / C$s(//^G �jj`p�/7` //JC/!/017/•rC ,j/yrr t/ INTENDED USE TYPE OF WELL -- CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 ❑ DOME97IC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Vee [IN. CONCRETE PEDESTAL BY DRILLER:❑Vee [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 0/i^ccf PvSA Lscb P�e,be I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WO/K WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURRED INSPECTIONS AT 120014"-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIC—d X r /`w fT REX' Tltle 4'yTH6R/Ze0 1?E/p D.te .f Y—oo PLOT PUN 1D,—to Sole)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PTtOPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRFD FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Lo vsE .4Yf V i' e., c <` o �n A P.V� .NA,bit, .... 4 GpI1H� . df 50, ;. ..: P..0, .. , " I L.....: . F.C it Q cE' ` ... ...... ... .;..... _ . dx....s_ 5AN 1pG{Ui�1 CtJN`F'P ;... .....`: . .'..... PUBLIC H.eALT,,,S>RVIGES -NVIRONNIENTA::14 -ALTHS�oh S ... •.._ :.. q� DEPARTMENT USE ONLY Appllc.11 n Accented By N\i Dae �1�W A," Grout I-Poctlon By Dae Pump In.pectlon By Das DMUtr.tlen I-Pectlon By not. C.—If.: ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#/ SASH RECEIVED BY DATIE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro. 173(1/97)